17 year old female with vomitings and loose stools since 1 week

CASE:

17 year old female complaints of vomitings and loose stools since 1 week

CHIEF COMPLAINTS 

Vomitings since 1week

Loose stools since 1week

Fever since 3 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic One week back,she had outside food followed by which she developed loose stools and vomitings.

Loose stools:- 4-5episodes, water in consistency, non foul smelling, no blood tinged.

Vomitings:- 4-5 episodes, non projectile, non bilious,non foul smelling contents include food particles,Which subsided on taking medication,

Fever was incidious in onset, associated with chills and rigor,which subsided on taking medication

10years back,patient's mother observed swelling over the neck 4*4cm approximately and was diagnosed with HYPOTHYROIDISM and was on TAB.THYROXINE 25mcg....

Patient has history of eating slate pencils since 4 years.(5-6 slate pencils per day)

3 years ago :- history of itching and was taken to hospital which subsided on taking medication.

Since 3months patient is observing irregular menses,followed by dysmenorrhea,with clots.

Patient also complained of generalised weakness since 1week.

HISTORY OF PAST ILLNESS:

Known case of HYPOTHYROIDISM since 10years on TAB.THYROXINE 25mcg..

Not a known case of HYPERTENSION,DIABETES MELLITUS,ASTHMA, EPILEPSY.

PERSONAL HISTORY:

DIET:Mixed(non veg twice weekly)

APPETITE:Normal

SLEEP: Adequate

BOWEL AND BLADDER MOVEMENTS: Regular

ADDICTIONS: No Addictions

ALLERGY:Present 3years ago, subsided on taking medication.

FAMILY HISTORY:

Mother was a known case of THYROID and was on TAB.THYROXINE 100mcg..

GENERAL EXAMINATION:

Patient was conscious,coherent and cooperative,well oriented to time,place and person.

Pallor:++

Hyperpigmentation notes over the palate and the buccal mucosa 

Knuckle pigmentation

Hyperpigmentation over the palmar creases 

Acanthosis nigricans ++

Icterus:- absent

Cyanosis:- absent

Clubbing:- absent

Lymph nodes:- Bilateral cervical and submandibular lymph nodes palpable.

Vital signs:

BP:- Supine :- 130/80 mm Hg 

        Standing :- 120/60 mm Hg

PULSE RATE :- Supine :- 88 BPM 

                           standing :- 83 BPM 

SPO2 :- 98 

Respiratory Rate :- 18cpm

GRBS :- 98 mg/dl

SYSTEMIC EXAMINATION:

CVS:S1,S2 heard,no murmurs

RESPIRATORY SYSTEM:

Inspection: trachea central in position, chest moving bilaterally equally with respiration.

Palpation:

Percussion :- resonant in all the fields

Auscultation :- Normal vesicular breath sounds heard.

BAE ++

LOCAL EXAMINATION:

Inspection:swelling at the anterior part of the neck,does not move with protrusion of tongue and moves with deglutition

Palpation :- disseminated margins,nodular,

                        size:6*7cms

Percussion :- 

Auscultation :- no bruits

ABDOMINAL EXAMINATION:

Inspection :- no scars

Palpation :- soft,non tender

Auscultation :- BOWEL SOUNDS HEARD 

CNS EXAMINATION:

CRANIAL NERVES: INTACT 

Power

Rt UL-5/5. Lt UL-5/5 

Rt LL-5/5. Lt LL-5/5 

Tone-

Rt UL -N

Lt UL-N

Rt LL-N

Lt LL-N

Reflexes:. RIGHT LEFT

Biceps. ++ ++

Triceps. ++ ++

Supinator. ++ ++

Knee. ++ ++

Ankle. ++ ++

Plantar:. Flexion Flexion       

•SENSORY

crude touch N N

              Pain N N

Temperature N N

     Fine touch N N

       Vibration Right Left

     Upper limb. 15 sec 15 sec

     Lower limb. 11 sec. 10sec

                Tibia. 14 sec. 14sec

                   Toe. 15sec. 15sec

Finger nose co-ordination : +

FEVER CHART:

INVESTIGATIONS:

HAEMOGRAM:

SERUM IRON:

FERRITIN LEVELS:

PHOSPHOROUS LEVEL:

SERUM CALCIUM:

ULTRASOUND NECK:

CHEST X-RAY:

PERIPHERAL SMEAR:

Diagnosis :- DIMORPHIC ANEMIA

ECG:

Provisional diagnosis:

 pernicious anemia with autoimmune thyroiditis ?

Addison's disease ?

TREATMENT:

1.NALMOL 

2.TAB.PANTOP 40mg BD

3.TAB.ZOFER 4mg SOS

4.TAB.SPOROLAC (ROUTE:PERORAL) BD

5.TAB.DOLO 650mg SOS

6.TAB.THYRONORM 25mcg OD

7.ORS SACHET IN 1LT WATER TO DRINK AFTER EACH LOOSE STOOLS.

8.VITALS STORING EVERY 4TH HRLY